Get Involved
The Ranch
Contact
Application
Get Involved
The Ranch
Contact
Application
Application
Application Phase 1
To nominate a child for the outdoor experience, please fill out the form and click submit. A representative will be in touch once the application is complete.
For additional information, please contact us at 281-477-6544.
Name
*
Name
First Name
Last Name
Email Address
*
Comments
*
Child Name
Child Name
First Name
Last Name
Child Age
Date Of Birth
*
Child Nickname
Physician Name
Physician Name
First Name
Last Name
Physician Address
Physician Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Physician Phone
Physician Phone
(###)
###
####
Physician Contact
May we contact your family physician?
Yes
No
Parent/Guardian 1 Info
Mother
Father
Legal Guardian
Parent/Guardian 1 Name
Parent/Guardian 1 Name
First Name
Last Name
Parent/Guardian 1 Primary Phone
Parent/Guardian 1 Primary Phone
(###)
###
####
Parent/Guardian 1 Cell Phone
Parent/Guardian 1 Cell Phone
(###)
###
####
Parent/Guardian 1 Address
Parent/Guardian 1 Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent/Guardian 1 Email
Parent/Guardian 2 Info
Father
Mother
Legal Guardian
Parent/Guardian 2 Name
Parent/Guardian 2 Name
First Name
Last Name
Parent/Guardian 2 Work Phone
Parent/Guardian 2 Work Phone
(###)
###
####
Parent/Guardian 2 Cell Phone
Parent/Guardian 2 Cell Phone
(###)
###
####
Parent/Guardian 2 Address
Parent/Guardian 2 Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent/Guardian 2 Email
Parent/Guardian 3 Info
Father
Mother
Legal Guardian
Parent/Guardian 3 Name
Parent/Guardian 3 Name
First Name
Last Name
Parent/Guardian 3 Work Phone
Parent/Guardian 3 Work Phone
(###)
###
####
Parent/Guardian 3 Cell Phone
Parent/Guardian 3 Cell Phone
(###)
###
####
Parent/Guardian 3 Address
Parent/Guardian 3 Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent/Guardian 3 Email
Sibling Info
Names and ages of sibling(s) living in the same household.
Parental Info
If parents divorced or separated, please list the parent the child lives with.
Father
Mother
Legal Custody
Does the parent have legal custody?
Yes
No
Legal Custody Info
If the child is not in legal custody of either parent, please explain the relationship of the guardian.
Race
Please share information about the race of the student.
Caucasian
African American
Hispanic
Asian
Other
Active Military
Is the child an active duty military dependent?
Yes
No
Active Military Info
If yes, which branch of service?
Physical Info
Does the child have any physical limitations that must be accommodated during an outdoor adventure?
Outdoor Adventure Info
Has the child ever had an outdoor wish granted?
Yes
No
Applied, but not received
Hunter Safety Course
Has the child completed a hunter safety course?
Yes
No
Hunter Safety Info
If yes, please list state issued and certificate number of hunter safety course.
How Did You Hear About The Children's Refuge?
Please share how you heard about us.
Is your child undergoing regular treatments?
If yes, please explain.
Approval Info
If approved, will the child and family be able to travel within 90 days? If the answer is "no", please explain:
Social Worker Info
Does the child have a Social Worker or Child Life Specialist? If so, please provide Name, Address, Phone and Email:
Waiver Of Liability
If the child is approved for the The Children's Refuge Outdoor Adventure, a parent or guardian will be required to sign a Waiver of Liability (Check box if you understand a waiver is required)?
Yes
No
Photo/Video Release
I give permission for photographs and video of my child to be shared on social media, promotions, or public use on websites and printed materials.
Yes
No
I am
Please share your relationship to the child.
Child's Parent
Child's Guardian
Friend
Family Member
Other
Thank you!
